NICE sepsis guideline

Sepsis: recognition, diagnosis and early management

Identifying people with suspected sepsis

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Think 'could this be sepsis?' if a person presents with signs or symptoms that indicate possible infection

Take into account that people with sepsis may have non-specific, non-localised presentations, for example feeling very unwell, and may not have a high temperature

Pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour

Assess people who might have sepsis with extra care if they cannot give a good history (for example, people with English as a second language or people with communication problems)

Assess people with any suspected infection to identify:

possible source of infection

factors that increase risk of sepsis

any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration

Identify factors that increase risk of sepsis or indications of clinical concern such as new onset abnormalities of behavior, circulation or respiration when deciding during a remote assessment whether to offer a face-to-face-assessment and if so, on the urgency of face-to-face assessment

Use a structured set of observations to assess people in a face-to-face setting to stratify risk if sepsis is suspected

Suspect neutropenic sepsis in patients having anticancer treatment who become unwell

suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth

intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis

parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth (this does not refer to intrapartum antibiotic prophylaxis)

suspected or confirmed infection in another baby in the case of a multiple pregnancy

Face-to-face assessment of people with suspected sepsis

Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis

Assess temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation and capillary refill time in children under 12 years with suspected sepsis

Measure blood pressure of children under 5 years if heart rate or capillary refill time is abnormal and facilities to measure blood pressure, including a correctly-sized blood pressure cuff, are available

Measure blood pressure of children aged 5 to 11 years who might have sepsis if facilities to measure blood pressure, including a correctly-sized cuff, are available

Only measure blood pressure in children under 12 years in community settings if facilities to measure blood pressure, including a correctly-sized cuff, are available and taking a measurement does not cause a delay in assessment or treatment

Measure oxygen saturation in community settings if equipment is available and taking a measurement does not cause a delay in assessment or treatment

Examine people with suspected sepsis for mottled or ashen appearance, cyanosis of the skin, lips, or tongue, non-blanching rash of the skin, any breach of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection

Ask the person, parent or carer about frequency of urination in the past 18 hours

Stratifying risk of severe illness or death from sepsis

Use the person's history and physical examination results to grade risk of severe illness or death from sepsis using criteria based on age (see tables 1, 2 and 3)

Adults, children and young people aged 12 years and over

Table 1: Risk stratification tool for adults, children and young people aged 12 years and over with suspected sepsis

Category

High risk criteria

Moderate to high risk criteria

Low risk criteria

History

Objective evidence of new altered mental state

History from patient, friend or relative of new onset of altered behaviour or mental state

History of acute deterioration of functional ability

Impaired immune system (illness or drugs including oral steroids)

Trauma, surgery or invasive procedures in the last 6weeks

Normal behaviour

Respiratory

Raised respiratory rate: 25 breaths per minute or more

New need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)

Raised respiratory rate: 21–24 breaths per minute

No high risk or moderate to high risk criteria met

Blood pressure

Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40mmHg below normal

Systolic blood pressure 91–100mmHg

No high risk or moderate to high risk criteria met

Circulation and hydration

Raised heart rate: more than 130 beats per minute Not passed urine in previous 18 hours For catheterised patients, passed less than 0.5 ml/kg of urine per hour

Children, young people and adults with suspected sepsis

Ask the person with suspected sepsis and their family or carers about any recent fever or rigors

Take into account that some groups of people with sepsis may not develop a raised temperature. These include:

people who are older or very frail

people having treatment for cancer

people severely ill with sepsis

young infants or children

Take into account that a rise in temperature can be a physiological response, for example after surgery or trauma

Heart rate in suspected sepsis

Interpret the heart rate of a person with suspected sepsis in context, taking into account that:

baseline heart rate may be lower in young people and adults who are fit

baseline heart rate in pregnancy is 10–15 beats per minute more than normal

older people with an infection may not develop an increased heart rate

older people may develop a new arrhythmia in response to infection rather than an increased heart rate

heart rate response may be affected by medicines such as beta-blockers

Blood pressure in suspected sepsis

Interpret blood pressure in the context of a person's previous blood pressure, if known. Be aware that the presence of normal blood pressure does not exclude sepsis in children and young people

Confusion, mental state and cognitive state in suspected sepsis

Interpret a person's mental state in the context of their normal function and treat changes as being significant

Be aware that changes in cognitive function may be subtle and assessment should include history from patient and family or carers

Take into account that changes in cognitive function may present as changes in behaviour or irritability in both children and in adults with dementia

Take into account that changes in cognitive function in older people may present as acute changes in functional abilities

Oxygen saturation in suspected sepsis

Take into account that if peripheral oxygen saturation is difficult to measure in a person with suspected sepsis, this may indicate poor peripheral circulation because of shock

Managing suspected sepsis outside acute hospital settings

Refer all people with suspected sepsis outside acute hospital settings for emergency medical care by the most appropriate means of transport (usually 999 ambulance) if:

they meet any high risk criteria (see tables 1, 2 and 3) or

they are aged under 17 years and their immunity is impaired by drugs or illness and they have any moderate to high risk criteria

Assess all people with suspected sepsis outside acute hospital settings with any moderate to high risk criteria to:

make a definitive diagnosis of their condition

decide whether they can be treated safely outside hospital

If a definitive diagnosis is not reached or the person cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care

Provide people with suspected sepsis, who do not have any high or moderate to high risk criteria information about symptoms to monitor and how to access medical care if they are concerned

Antibiotic treatment in people with suspected sepsis

Pre-alert secondary care (through GP or ambulance service) when any high risk criteria are met in a person with suspected sepsis outside of an acute hospital, and transfer them immediately

Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in locations where transfer time is more than 1 hour

If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings

For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance

Using oxygen in people with suspected sepsis

Give oxygen to achieve a target saturation of 94–98% for adult patients or 88–92% for those at risk of hypercapnic respiratory failure

Oxygen should be given to children with suspected sepsis who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated

Finding the source of infection in people with suspected sepsis

Carry out a thorough clinical examination to look for sources of infection, including sources that might need surgical drainage, as part of the initial assessment

Tailor investigations of the sources of infection to the person's clinical history and findings on examination

Information and support for people with sepsis and their families and carers

People who have sepsis and their families and carers

Ensure a care team member is nominated to give information to families and carers, particularly in emergency situations such as in the emergency department. This should include:

an explanation that the person has sepsis, and what this means

an explanation of any investigations and the management plan

regular and timely updates on treatment, care and progress

Ensure information is given without using medical jargon. Check regularly that people understand the information and explanations they are given

Give people with sepsis and their family members and carers opportunities to ask questions about diagnosis, treatment options, prognosis and complications. Be willing to repeat any information as needed

Give people with sepsis and their families and carers information about national charities and support groups that provide information about sepsis and the causes of sepsis

Information at discharge for people assessed for suspected sepsis, but not diagnosed with sepsis

Give people who have been assessed for sepsis but have been discharged without a diagnosis of sepsis (and their family or carers, if appropriate) verbal and written information about:

what sepsis is, and why it was suspected

what tests and investigations have been done

instructions about which symptoms to monitor

when to get medical attention if their illness continues

how to get medical attention if they need to seek help urgently

Confirm that people understand the information they have been given, and what actions they should take to get help if they need it

Information at discharge for people who have had sepsis

Ensure discharge notifications to GPs include the diagnosis of sepsis

Training and education

Ensure all healthcare staff and students involved in assessing people's clinical condition are given regular, appropriate training in identifying people who might have sepsis. This includes primary, community care and hospital staff including those working in care homes

Ensure all healthcare professionals involved in triage or early management are given regular appropriate training in identifying, assessing and managing sepsis. This should include:

risk stratification strategies

local protocols for early treatments, including antibiotics and intravenous fluids

criteria and pathways for escalation, in line with their health care setting

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.